Contractor Interest Form for Emergency Work

Immediately following storms, earthquakes or other natural disasters, Caltrans often
elects to immediately contract with highway construction firms to begin clean-up and
repair work. To maximize Caltrans' readiness for future disasters and to give all
contractors an opportunity to tell us about your capabilities and experience, we are
inviting contractors to register their interest with Caltrans.

Completion of this form
will enter your company's name and information into a Caltrans registry of contractors
interested in possibly receiving contracts for emergency repairs or equipment rental in
the event of a disaster.

DISCLAIMER: Registering with Caltrans does not represent any express or implied promise
by Caltrans to award emergency contracts now or in the future. Caltrans is not bound to
select contractors from the registry. Data entered will be held in confidence and will not
be shared with other firms without the contractors consent.

Fields
marked with * are required.

Company Information

Name of Firm*

Main office
Branch office

Street*

City*

State*

Zip

Phone (Day)*

(
)
-

Phone (24 hr)

(
)
-

FAX

(
)
-

email

Contractor's License(s)

California Contractor's License. Make the appropriate selection under License No. 1. If you have more than one license, fill out No. 2 and No. 3, otherwise leave them blank.

California Contractor's
License No. 1 *

(If you don't have a license, select "None" under
"Type")

California Contractor's License No.
Type *
Expires //

California Contractor's
License No. 2

California Contractor's License No.
Type
Expires //

California Contractor's
License No. 3

California Contractor's License No.
Type
Expires //

Bonding and Certification

Surety Bond? Yes No Coverage $

Certified As (check all that apply)Small Business DBE DVBE

Preferred Work Locations

Check those regions which your firm prefers to work and can quickly
mobilize if needed.